Set ground rules for drug rep interactions
■ A column that answers questions on ethical issues in medical practice
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Nov. 7, 2005.
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A member of your staff stops you and asks, "The drug rep is waiting to see you. Do you have a moment?"
Budgeting time from my clinical or research day for unexpected interruptions, let alone pharmaceutical reps, is often challenging. When I make time for a drug rep I expect something of value in return. Am I compromising my integrity and ethics during these brief encounters?
My first encounter with a drug rep as a practicing physician was in rural Canada. Our community health center consisted of 10 doctors and several nurse practitioners. The head physician asked me to come in and "say hi to the rep."
The actual drug and accompanying message are long gone from my memory, but the words that the head physician shared with me immediately afterwards still reverberate in my head: "Sam, you just have to listen to what the rep says, say you will prescribe the drug, sign for samples then shake hands." Those were the good old days.
Of late, greater scrutiny regarding physician-drug rep relations is the norm. The AMA's position statement on gifts to physicians from the drug industry, first published in 1991, has been updated to reflect current medical practice. The Pharmaceutical Research and Manufacturers of America since has adopted these updated guidelines.
In the past five years, more studies and statements have been shared concerning physicians' and medical trainees' attitudes toward physician-drug rep interactions and the pharmaceutical industry. An article in a recent Journal of the American Medical Association concluded that physicians and medical students are at risk for unrecognized influence by pharmaceutical marketing.
These studies and guidelines give me reason to pause. I wonder if the recommendation that "a physician not accept anything of value" for his time has usurped my right to decide whether or not I am reimbursed for my professional time and opinion. My patients value the time that we share, and I am reimbursed accordingly. Why provide compensation for one professional endeavor and not another?
It is clear that physicians' prescribing patterns are influenced at least to some extent by interactions with the drug industry.
As an independent physician, however, I claim the right to choose whether or not to be influenced.
With whom I interact on a day-to-day basis should be my decision. Some physicians interact with drug reps only when they need samples for their patients. Others listen to drug reps to hear the latest formulation or dosing modification. Yet others listen to drug reps only when there are obvious and immediate rewards such as free office paraphernalia or invitations to drug industry-sponsored educational symposia, discussions or dinners. Some do all of the above; others do none of the above.
Any time that I allow for drug reps as well as time for the receipt of drug samples, agreements to pass along patient information or decisions about paraphernalia needs to remain at my discretion.
I recognize that drug reps still do want to achieve a common goal that is blatantly obvious: Increase physician prescribing to sell more of their drugs.
My latest encounter with a drug rep confirmed this point. Of all the educational messages that this drug rep shared with me, the final message relayed to me was the following: "So, doctor. Will you prescribe more of product X?"
The fact is that a physician has decision-making power over whether to see a drug rep or not. To maintain control over this interaction, I like to specify that drug reps come only at designated times of the day, preferably early in the morning before clinic, during lunch or at a mutually convenient time. Occasionally, I advise staff to inform the drug rep to drop off samples with the accompanying sales slip and empower my nurse or designee to sign for me. Also, I ask the rep to make an appointment to see me. Usually, I request literature that is not sponsored by industry to back up statements of efficacy. I also call the rep to inform him or her of our new office policy concerning drug rep visits. The response from the drug rep has been consistent: "OK, doctor."
To paraphrase Stephen Covey, author of The 7 Habits of Highly Effective People, my encounters with drug reps are a "win-win situation."
Currently, I work at an academic institution. The policy in place and its enforcement regarding physician-drug rep relations is under constant observation. This is good. But for those physicians who see the positives of the drug rep visits, such as learning the latest dosing, formulations, indications and precautions regarding drugs, the opportunity to interact with drug reps is still there.
In fact, I enacted such opportunities as program director at the University of Illinois at Chicago Family Medicine Residency. During my tenure, not only did I encourage drug reps to sponsor lunch, I even invited the residents. I did this with several goals in mind:
- Educate the residents, in a controlled environment, about the latest drugs and their relative values in treating patients' diseases.
- Ask physicians and pharmacists to attend these sessions and debrief the residents immediately after the drug-rep presentations to present a fair, balanced picture of the particular drug(s).
- Model professional behavior among physicians and pharmacists when interacting with drug reps.
- Ensure that any item of value that drug reps offer is strictly appropriate and medically related.
- Provide a conduit for drug reps to interact with residents rather than having drug reps go directly to these trainees without the benefit of practicing physicians' educational oversight.
Over the years, residents often have thanked me for organizing these sessions and asked for additional educational forums. Consequently, I informed the inpatient medical director of our family medicine program of my intention to invite the occasional drug industry-sponsored guest physicians to make occasional presentations to our morning report. This venue attracted many more practicing physicians to participate. Morning reports became a hub of collegiality and learning while reinforcing the value that the drug industry and their reps possessed in promoting continuing medical education.
My professional time is valuable. Like-minded colleagues who value their time feel comfortable receiving something of value in return for sharing their time and interest. Those doctors who don't retain control over these encounters eventually will resent the intrusion and lose interest in giving their time away.
These encounters over the years have proven to be of value in my practice and have spawned a handful of wonderful professional relationships.
I value drug rep encounters that share educational support materials, up-to-date knowledge, professional courtesy and respect.
I also value my right to choose.
Samuel N. Grief, MD, assistant professor in clinical family medicine, University of Illinois at Chicago
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.